Medicaid BuyIn for Workers with Disabilities

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Medicaid Buy-In for Workers with Disabilities

• Donna Folkemer
• National Conference of State Legislatures
• and APHSA Center for Workers with Disabilities
• November 2003

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What is a Medicaid Buy-In?

• A separate Medicaid eligibility category, set up
  under state option and under state rules, for
  persons with disabilities who are working and who
  otherwise would not qualify for Medicaid.
• The term Buy-In has been used to describe other
  Medicaid-related things, so its important to
  understand terminology.

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Which States have Medicaid Buy-In Programs?

• 12 States with Programs Authorized by Balanced
  Budget Act of 1997
• Alaska, California, Iowa, Maine, Mississippi,
  Nebraska, New Mexico, Oregon, South Carolina,
  Utah, Vermont, and Wisconsin.
• 12 States with Programs Authorized by Ticket to
  Work Legislation of 1999
• Arkansas, Connecticut, Illinois, Indiana, Kansas,
  Minnesota, Missouri,New Hampshire, New Jersey,
  Pennsylvania, Washington, Wyoming.

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States with Buy-In Programs (continued)

• Two (2) states have similar programs now under
  the authority of a Section 1115 waiver AZ and
  MA.
• In 2003, 6 states passed Buy-In legislation.
  Those states are LA, MD, MI, ND, VA, WV.
• Of these states, 3--MI, ND, and WV--called for
  starting programs in 2003. One state--LA--authoriz
  ed a program by 1/04, one state--MD--authorized a
  program (subject to budget considerations) to
  begin by July 2005, and one state--VA--called
  for an 1115 waiver program.

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States with Buy-In Programs

• All told, 32 states with current program or some
  sort of future activity.
• What about the others? No program authorized at
  this point. But working on through grant programs
  and stakeholder groups.

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Medicaid Buy-In Key ConceptsEligibility Group

• Balanced Budget Act Eligibility Group
• TWWIIA Eligibility Group
• Major differences
• 250 of poverty maximum in BBA no maximum in
  TWWIIA
• No age limit in BBA ages 16 to 64 in TWWIIA.
• Processes for setting income and resource
  standards somewhat different.

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Key Concept--Cost Sharing

• Both BBA and Ticket Act make provision for
  beneficiary cost-sharing with states having
  flexibility in its design.
• Most states use a premium structure with payments
  required for persons with incomes above a
  specified level. Two states use a co-payment
  system designed for this eligibility group.
• About half of participants pay premiums. In 2002,
  average premium in states ranged from 12 to 321
  per month.

8
How Many People Are Enrolled in Buy-In Programs
Nationally?

• 44,000 /- as of December 2002.
• 63,000 /- since inception of program.
• Number of enrollees varies from 150 (Washington
  State) to 8000 (Missouri).

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Most Important Concept

• Just as no two states have the same rules for
  other Medicaid categories, no two states have the
  same rules for their Medicaid Buy-in Programs.
• Look carefully at program design features.
• Look carefully at how program connects to other
  Medicaid groups.

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Variation in Design Features

• Income standard
• Separate unearned income standard?
• Asset rules
• Asset accumulations possibility?
• Premium structure and other cost-sharing features

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Two State Examples

• Minnesota
• No income limit
• Premiums of from 1 to 7.5 of income beginning
  at 100 of poverty based on gross income.
• 20,000 Asset Limit
• Retirement and Medical Savings Accounts not
  counted as assets.

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Two State Examples

• Maine
• Person must meet two income tests Countable
  earned and unearned income of less than 250 of
  poverty AND countable unearned income below 100
  of poverty.
• Asset limits of 8000 for individual or 12,000
  for a couple. No asset accumulation feature.
• Premiums begin at countable income level of 150
  of poverty and are 10 or 20 per month based on
  income

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Relationship to Other Eligibility Categories

• Eligibility due to SSI status
• SSI 1619(b) option
• Medically needy programs
• Optional poverty level category

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Relationship to Other Eligibility Categories

• For medically needy, replaces spend-down with
  predictable premium or no premium.
• Thus may be particularly helpful to SSDI
  recipients who previously were spend-down.
• For SSI people, helpful for those who want to
  retain more income and assets than possible under
  1619(b).

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Policy Issue

• How to make Buy-In a real work incentive leading
  to increased earnings.
• Definition of work not allowed, but some state
  are requiring FICA proof.
• Buy-in does not change SSDI rules so there is
  still a cash cliff.
• Premium structure and other design features
  influence enrollment, earnings, and service use,
  but more analysis needed.

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Information Sources

• The Medicaid Buy-In Program Quantitative
  Measures of Enrollment Trends and Participant
  Characteristics in 2002. October 2003.
  Mathematica Policy Research (for CMS).
• http//www.cms.hhs.gov/twwiia/mathrpt1003.pdf
• http//cms.gov/twwiia/statemap.asp for state by
  state description of programs.

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Information Sources

• GAO Report Medicaid and Ticket to Work States
  Early Efforts to Cover Working Individuals with
  Disabilities--June 2003.
• Www.gao.gov/cgi-bin/getrpt?GAO-03-587
• State Medicaid Options that Support the
  Employment of Workers with Disabilities. By
  Pamela Hanes and Jessica Folkman. August 2003.
• http//www.chcs.org/publications/pdf/cas/BuyIn.pdf